Repeat per-oral endoscopic myotomy (POEM) procedures are safe and efficacious for patients with persistent symptoms following initial POEM in the management of achalasia, according to research results of a multicenter, international examination published in Gastrointestinal Endoscopy.

Achalasia is a motility disorder which results from the loss of myenteric neurons and impaired relaxation of the lower esophageal sphincter. Consecutive patients with persistent symptoms following initial POEM procedure were enrolled in a prospective registry (NCT02162589). Repeat procedures were conducted in 15 academic centers across 9 countries. 

The study cohort included 46 patients (mean age 49.3±16.78 years; 45% men). Achalasia breakdown included 10 patients with type I achalasia, 16 patients with type II achalasia, 5 patients with type III achalasia, and 15 patients with other esophageal dysmotility disorders. Mean preprocedure Eckardt score was 4.3±2.48 with an average disease duration of 9.6 years. The average time between myotomies was 12.2 months (range 1-32 months).

The researchers examined demographic and procedural information to determine the predictors of clinical failure of the initial POEM procedure. Before the first POEM, 43% of patients underwent dilation, 4% underwent botox injection, and 1 patient underwent both. Eckardt score was 6.7±2.4. Seventy-six percent of patients had an anterior POEM performed; 20% had a posterior POEM. Subgroup analyses indicated that “neither previous intervention or myotomy approach…was a significant predictor of clinical failure.”

Following the repeat POEM procedure, 100% of patients experienced technical success. Anterior or posterior approaches were chosen based on the approach used in the initial procedure. Clips were the most common closure method (91% of patients), followed by endoscopic suturing (4%).

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Eighty-five percent of patients achieved clinical success, with an average postprocedure Eckardt score of 1.64±1.67. One patient was lost to follow up; of the 5 patients who did not achieve clinical success, 1 had achalasia type I, 1 had achalasia type II, and 3 had achalasia type III.

Eight patients (17%) experienced procedural bleeding. This adverse event was managed endoscopically at the time of the procedure. No deaths, anesthesia-related or postprocedural adverse events were noted, and no POEMs “were aborted or required laparoscopic conversion or surgical intervention.”

Study limitations include a lack of standardization of technique across the included centers, as well as limited follow-up data — only short-term data were collected to evaluate procedure efficacy.

“For patients with persistent symptoms after POEM, repeat POEM appears to be an efficacious and safe technique,” the researchers concluded. “Additional prospective studies and long-term follow-up data are required.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Tyberg A, Seewald S, Sharaiha RZ, et al. A multicenter international registry of redo per-oral endoscopic myotomy (POEM) after failed POEM. [published online October 15, 2016]. Gastrointest Endosc. doi: 10.1016/j.gie.2016.10.015